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AUTOSCOPY 


OF    THE 


Larynx  and  the  Trachea 

(Direct  Examixation  AVithout  Mireok.) 


ALFRED  KIRSTEIN,  M.D., 

Berlix. 


Authorized  Translateon  (Altered,  Enlarged,  and 
Revised  by  the  Author)  by 

MAX  THORNER,  A.M.,  M.D., 

Cincinnati,  O., 

Professor  of  Clinical  Laryngology  and  Otology,  Cincinnati  College  of  Medicine 

AND  Surgery;   LARYNcOLOGfST  and  Aurist,  Cincinnati 

Hospital,  etc. 


WITH    TWEIiVe    IIiIiUSTf^HTIOJlS. 


PIIILADET.PHIA  . 

THE  F.  A.  DAVIS  CO.,  Publishers. 

1897. 


2859 


COPYRIGHT,  1896, 

BY 

THE  F.  A.  DAVIS  COMPANY. 


[Registered  at  Stationers'  Hall.  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A. : 

The  Medical  Bulletin  Printing- House, 
1916  Cherry  Street. 


TO 

J.  SOLIS-COHEN,  M.D., 

OF  PHILADELPHIA, 

THIS  TRANSLATION   IS   DEDICATED, 

IN 

Grateful  recognition  of  much  personal 

kindness, 

BY 

The  Translator  and 
Editor. 


(iii) 


PREFACE. 


EvEE  since  the  time  when  progressive  minds 
first  endeavored  to  get  a  view  of  the  interior  of 
the  human  larynx  they  have  been  under  the  im- 
pression that  the  way  from  the  mouth  to  the 
vocal  cords,  according  to  existing  anatomical 
conditions,  must  of  necessity  form  an  angle. 
Under  the  influence  of  this  conception,  the 
truth  of  which  no  one  ever  seemed  to  doubt, 
no  plan  could  have  been  conceived  other  than 
the  one  which  finally,  in  the  sixth  decade  of  our 
century,  resulted  in  the  discovery  of  laryngo- 
scopy by  Garcia,  Turck,  and  Czermak, — namely, 
to  overcome  this  difficulty  by  means  of  a  re- 
flecting apparatus  (a  mirror)  placed  at  the  apex 
of  the  angle,  or  the  introduction,  into  medicine, 
of  the  laryngoscope,  the  laryngological  tech- 
nique entered  upon  a  path  of  development  from 
which  it  has  hitherto  not  departed  in  the  slight- 
est degree.  The  introduction  of  endolaryngeal 
surgery  by  Victor  Bruns  was  the  next  brilliant 
development  of  Turck's  and  Czermak's  great 

(V) 


VI  PREFACE. 

invention.  Cocaine  has  freed  laryngological 
surgery  from  its  many  difficulties  without  at 
all  changing  its  method.  Thus,  there  has  been 
but  one  creative  thought  which  has  hitherto 
directed  all  our  laryngological  methods  of  ex- 
amination and  treatment. 

It  may  appear  a  rash  undertaking  for  me 
to  deviate  from  time-honored  tradition,  and  to 
open  up  an  entirely  new  way  for  the  examina- 
tion and  treatment  of  the  larynx  and  the  tra- 
chea, by  teaching  that  we  can  view  the  interior 
of  the  air-passages  directly,  without  the  aid  of 
optical  appliances,  and  operate  with  straight 
(uncurved)  instruments  in  the  same  manner. 
Nevertheless,  my  undertaking  is  doubly  justi- 
fied. In  the  first  place,  because  of  the  facts 
themselves,  which  may  be  demonstrated  at  any 
time,  and  which  I  have  made  known  in  a  series 
of  publications  entitled  "  Autoscopy  of  the  Air- 
Passages."  *  The  fact  that  we  have,  up  to  this 
time,  never  viewed  the  interior  of  the  larynx 
directly  (without  a  mirror)  is  certainly  not  due 

*  Allgem.  med.  Centralzeitung,  1895,  No.  34 ;  Berl.  klin.  Woch- 
enschrift,  1895,  No.  22 ;  Archiv  f,  Laryngologie  mid  Rhlnologie,  Bd. 
ii,  1,2;  Therapeut.  Monatshefte,  July,  1895;  Deutsche  med.  Woeh- 
enschrift,  1895,  No.  38. 


PREFACE.  Vii 

to  logical  reasoning,  but  because  we  had  no 
idea  of  such  a  possibility.  Since,  however,  we 
have  discovered  that  it  can  be  done,  and  how 
we  can  do  it,  there  can  be  no  possible  objection 
raised  to  our  making  full  use  of  our  new  knowl- 
edge and  ability.  In  the  second  place,  this 
method  is  not  intended  to  replace  the  laryngo- 
scopic  method,  but  to  add  to  it.  I  must  decid- 
edly deny  any  prejudice  on  my  part  toward  the 
laryngoscopic  method ;  the  very  fact  that  I  my- 
self have  shown  that  my  direct  method  cannot 
render  the  indirect  method  superfluous  throws 
into  strong  light  the  value  of  the  laryngeal  mir- 
ror. Of  course,  many  a  laryngologist  is  con- 
vinced that  the  laryngological  technique  needs 
no  additions;  others  may  think  differently. 
Only  the  future   can   decide   this   question. 

KlESTEIN. 
BERiiiN,  January,  1896. 

All  the  instruments  described  in  this  mono 
graph  are  manufactured  by  W.  A.  Hirschmann, 
Berlin,  N.     They  may  also  be  procured  from 

Messrs.  Krohne  &  Sesemann,  Duke  Street, 
8  Manchester  Square,  London,  W. 


Vlll  PREFACE. 

Mayer  &  Meltzer,  71  Great  Portland  Street, 
London,  W. 

Ottomar  Carliczek,  56  Dearborn  Street,  Chi- 
cago, 111. 

Max  Wocher  &  Son,  23  W.  Sixth  Street, 
Cincinnati,  0. 

Denyer  Brothers,  272  Swanston  Street  (next 
Lonsdale  Street),  Melbourne,  Australia. 


PREFACE  OF  THE  TRANSLATOR. 


This  translation,  made  at  the  request  of  the 
author,  is  in  reality  a  second  edition  of  the 
original  German  monograph.  Dr.  Kirstein  has 
placed  so  much  new  material  at  my  disposal, 
changing  and  adding  to  the  original  work  to 
such  an  extent  that  alterations  will  be  notice- 
able on  almost  every  page.  A  number  of  illus- 
trations are  entirely  new;  others  have  been 
improved.  Several  additions  have  become 
necessary  from  time  to  time,  as  the  transla- 
tion progressed,  in  accordance  with  the  im- 
provements and  modifications  which  were 
gradually  developed  by  the  author.  While 
the  translation  was  going  through  the  press 
the  author  published  some  very  important 
modifications  of  his  method,  simplifying  the 
technique  and  the  instrumentarium  to  a  con- 
siderable degree.  I  have  appended  an  abstract 
of  his  article  (page  63),  bringing  thus  the 
description   of  this   method  up  to   date. 

It  is  needless  to  say  that  I  consider  the 

(ix) 


X  PREFACE    OF    THE    TRANSLATOR. 

autoscopic  examination  of  the  air -passages,  as 
developed  by  Kirstein,  the  most  important 
addition  to  our  technical  resources  made  since 
the  discovery  of  the  laryngoscope  by  Garcia. 
And  I  have  no  doubt  that  henceforth  every 
one,  who  wishes  to  master  the  technique  of 
laryngology,  will  have  to  familiarize  himself 
with  this  —  after  all,  astonishingly  simple  — 
method  of  laying  the  air-passages  open  to 
direct  inspection. 

M.  Thoener. 

Cincinnati,  O.,  December,  1896. 


CONTENTS. 


PAGE 

Preface, 

V 

Translator's  Preface, 

.     ix 

Definition  and  Theory,     . 

.         .         .         .       1 

The  Technique, 

.      8 

I.  Illumination, 

.       8 

II.  The  Autoscope, 

.     15 

III.  AUTOSGOPY,         .... 

.     21 

Individual  Fitness  for  the  Autoscopic  Examination,    29 

Comparison  between  Autoscopy  and  Laryngoscopy,   .    35 

I.  Examination  of  Adults,      .        .        .        .        .35 

II.  Examination  of  Children, 44 

III.  Operations, 47 

Conclusion,    . 55 

Resume, 57 

Appendix, 59 

Additional  Notes  of  the  Translator,    .        .        .        .62 
I.  A  Foreign  Body  Removed  from  the  Larynx 

BY  THE  Translator, .62 

11.  Latest  Improvements  in  Autoscopy,         .        .     63 

(xi) 


AUTOSCOPY. 


DEFINITION  AND   THEORY. 


By  "autoscopy  of  the  air-passages"  I  under- 
stand the  direct  linear  inspection,  through  the 
mouth,  of  the  lower  pharynx,  the  larynx,  the 
trachea,  and  the  entrances  into  the  primary 
bronchi. 

The  necessary  conditions  of  such  a  complete 
linear  inspection  can  be  stated  a  priori  to  be : — 

1.  The  body  must  be  placed  in  such  a  po- 
sition that  an  imaginary  continuation  of  the 
laryngo- tracheal  tube  would  fall  within  the 
opening  of  the  mouth. 

2.  This  imaginary  straight  line  must  be 
cleared  of  those  parts  of  the  body  (epiglottis 
and  base  of  the  tongue)  which  obstruct  it. 

Regarding  No.  1.  When  the  military  po- 
sition is  assumed  the  continuation  of  the  wind- 
pipe would  strike  somewhere  in  the  neighbor- 
hood of  the  root  of  the  nose ;  when  the  head  is 

(1) 


2  AUTOscopr. 

bent  comfortably  backward,  as  in  looking  aloft, 
it  would  about  strike  the  chin ;  this  can  be 
made  clear  by  looking  at  any  person  in  the 
erect  position,  if  we  remember  that  the  trachea, 
the  upper  end  of  which  in  the  neck  lies  quite 
to  the  front,  runs  downward  and  backward 
through  the  thorax,  parallel  to  the  spinal  col- 
umn, forming  a  considerable  angle  with  the 
sternum.  The  position  adapted  for  "  auto- 
scopy"  must  therefore  be  somewhere  between 
the  two  positions  just  mentioned,  and  can  be 
easily  obtained  by  gently  tilting  the  head  up- 
ward until  the  axis  of  vision  forms  with  the 
axis  of  the  trunk  an  angle  of  about  135  de- 
grees. This  theoretical  consideration  is  fully 
borne  out  by  experience.  (Fig.  1.)  This  tilting 
movement  of  the  head  is  a  rotation  on  the 
atlanto-occipital  articulation.  I  do  not  believe 
that  the  flexibility  of  the  cervical  spinal  column 
is  to  any  extent  called  into  requisition.  The 
fact  that  a  small  angle  in  the  atlanto-occipital 
joint  will  produce  a  sufficiently  large  excursion 
of  the  superior  maxilla  is  explained  by  the  large 
radius  of  the  circle  of  rotation,  about  12  centi- 
metres. 


DEFINITION    AND    THEORY. 


Eegarding  No.  2.  The  base  of  the  tongue 
can,  of  course,  be  got  out  of  the  way  of  the  pro- 
longed trachea  in  but  one  direction, — namely, 


Fig.  1.— Position  for  Autoscopy. 

X  ^  atlanto-occipital  articulation.     >  =  axis  of  vision. 

forward  and  downward.  To  get  this  position 
of  the  tongue  a  tongue-depressor  is  necessary, 
— i.e.,  a  spatula, — which,  however,  unlike  the 
ordinary  spatula,  must  not  be  placed  in  front  of 


4  AUTOSCOPY. 

the  circumvallate  papillse,  but  must  be  applied 
behind  the  same,  to  the  root  of  the  tongue. 
The  epiglottis  can  be  elevated,  as  has  been  long 
known,  in  one  of  two  ways :  (1)  directly,  by  an 
instrument  which  projects  over  the  epiglottis 
(thus,  in  our  case,  most  easily  by  the  spatula 
itself,  the  tip  of  which  must  therefore  be  intro- 
duced behind  the  epiglottis) ;  (2)  indirectly,  by 
a  method  the  principle  of  which  was  described 
by  Reichert*  in  1879  as  follows :  Pressure  upon 
the  base  of  the  tongue  and  the  median  glosso- 
epiglottic  ligament  produces  an  elevation  of  the 
epiglottis  on  account  of  its  close  attachment  to 
the  tongue.  As  the  first  method  requires  pre- 
vious cocainization,  it  should  be  reserved  for 
exceptional  cases ;  autoscopy  must  depend,  in 
general,  on  the  principle  enunciated  by  Eei- 
chert, — a  principle  which  is  already  involved  in 
the  necessary  instrumental  depression  of  the 
base  of  the  tongue. 

The  patient  tilts  his  head  slightly  upward  and 
opens  his  mouth;  the  physician  presses  the  base 
of  the  patienVs  tongue  forward  with  a  spatula. 

*  "  Eine  neue  Methode  zur  Aufrichtung  des  Kebldeckels  bei  lar- 
yngoscopischeu  Operatiouen,"  Arch.  f.  klin.  Chirurgie,  Bd.  xxiv. 


DEFINITION    AND    THEORY.  5 

These  are  the  remarkably  simple  directions 
which  we  deduct  from  our  theoretical  consider- 
ations concerning  the  possibility  of  autoscopy. 
Looking  at  the  question  from  the  stand-point 
of  our  present  knowledge,  it  is  hard  to  see  how 
a  discovery  lying  so  near  at  hand  should  have 
been  so  long  overlooked.  One  would  imagine 
that  an  off -hand  glance  at  any  sagittal  section 
of  the  upper  part  of  the  body  would  have  suf- 
ficed to  suggest  the  idea  of  autoscopy.  The 
stimuhts  to  such  a  discovery,  however,  was 
apparently  wanting,  because  the  need  of  addi- 
tions to  our  laryngological  armamentarium  was 
nowhere  felt.  Whoever  would  conclude  from 
this  that  autoscopy  even  now,  after  it  has  be- 
come established,  fills  no  real  need,  might  have 
argued  with  the  same  logic  that  the  laryngeal 
mirror  is  superfluous  because  through  all  the 
preceding  centuries  there  was  no  demand  for  it 
until,  forty  years  ago,  it  was  discovered  by  a 
musician,  and  then  had  to  be  forced  upon  a 
profession — whose  duty  it  was  to  recognize  and 
treat  disease — not  by  a  practising  physician, 
but  by  a  physiologist. 

It  seems  to  me  even  more  remarkable  that 


6  AUTOSCOPY. 

chance,  which  has  so  often  led  to  discoveries, 
has  left  laryngology  so  completely  in  the  lurch 
in  this  particular.  At  present,  during  an  ordi- 
nary examination  of  the  pharynx,  in  depressing 
the  tongue  with  the  usual  angular  spatula,  we 
occasionally  get,  all  of  a  sudden,  a  full  view  of 
the  whole  arytenoid  cartilages  and  part  of  the 
vocal  cords,  sometimes  even  of  the  bifurcation  ; 
formerly  this  never  occurred.  I  can  only  ex- 
plain this  fact  by  supposing  that  the  diligent 
use  of  the  autoscope  leads,  in  depressing  the 
tongue,  to  a  special  dexterity  which  formerly 
was  scarcely  called  for.  By  practising  auto- 
scopy  we  acquire  an  entirely  new  way  of  intro- 
ducing the  spatula.  Our  preconceptions  re- 
garding the  awful  reflex  excitability  of  the 
base  of  the  tongue  we  soon  relinquish ;  we 
lose  our  timidity;  we  place  the  patient  in  a 
better  position;  we  no  longer  look  mainly  in 
an  horizontal  direction,  but  also  now  from 
above  downward.  Those  laryngologists  who 
are  accustomed  to  make  examinations  while 
standing  were  much  more  likely  to  make  the 
accidental  discovery  of  direct  laryngoscopy 
than  the  majority  who  use  the  laryngoscope 


DEFINITION    AND    THEORY. 


while  seated.  Time  will  show  that  autoseopy 
will  introduce  into  laryngological  technique  a 
certain  freedom  of  action  which  is  of  great 
advantage,  provided  it  is  not  overdone. 


THE  TECHNIQUE. 


I.   ILLUMINATION. 

Stationaby  appliances  of  illumination  {^^Sta- 
tivspiegeV^)  are  of  no  value,  not  only  for  auto- 
scopy  proper,  but  also  for  the  freer  method  of 
laryngoscopy  which  has  lately  come  into  vogue. 
The  cone  of  light  reflected  into  the  throat  must 
come  from  a  source  attached  to  the  observer 
himself,  so  that  it  can  readily  follow  his  slight- 
est movements,  and  thus  render  him  inde- 
pendent of  the  position  of  the  reflector.  The 
forehead-mirror  answers  these  requirements 
essentially,  though  not  quite  completely.  At 
all  events,  it  is  the  only  favorable  and  thor- 
oughly practical  instrument  for  autoscopy,  if 
we  use  sunlight,  or  have  to  depend  upon 
lamplight,  Argand  burners,  or  the  incandes- 
cent gaslight, — the  so-called  Wellsbach  light. 
Only  the  electric  light  renders  us  entirely  inde- 
pendent, or,  rather,  can  render  us  entirely  inde- 
pendent, if  we  avail  ourselves  of  its  possibil- 
ities. If  we  simply  substitute  an  incandescent 
(8) 


THE   TECHNIQUE.  9 

lamp  (with  or  without  a  condenser)  for  the  gas- 
light, and  use  a  forehead-mirror  according  to 
our  old   custom,  we  thereby  sacrifice,  for  the 
sake  of  a  traditional  method  based  upon  entirely 
different  conditions,  the  special  advantages  of 
the  electric  light.     Two  persons  are  necessary 
for  an  examination  of  the  throat :  a  patient  and 
a  physician.     The  classical  method  of  examina- 
tion requires  the  addition  of  an  entirely  super- 
fluous and  troublesome  element, — namely,  the 
lamp.     This  is  stationary,  and  may  not  be  dis- 
turbed; the  observer  must  regulate,  according 
to  its  position,  the  position  of  his  own  head, 
which  bears  the    forehead-mirror;   and  which 
should  be  moved  with  no  other  considerations 
than  the  position  of  the  patient.    Furthermore, 
the  lamp  must  be    shifted  when  the   patient 
bends,  and  must  be  raised  when  the  patient  is 
examined  according  to  Killian's  method;   and 
last,  but  not  least,  the   physician,  instead   of 
simply  giving  light,  is  himself  constantly  illu- 
minated and  blinded.     At  all  events,  this  is  at 
least  endurable,  and  without  the  electric  light 
there  is  no  other  way.     But  we  need  not  make 
a  virtue   of  our  necessity.     We   may  at  least 


10  AUTOSCOPY. 

admit  that  all  this  is  disagreeable  and  an  im- 
pediment, although  custom  has  blunted  us  to 
this  fact. 

The  electric  light  resembles  sunlight  more 
than  the  Wellsbach  light  does,  but  the  latter 
resembles  sunlight  sufficiently  for  all  practical 
purposes  of  laryngology.  The  pre-eminent 
value  of  the  incandescent  lamp  depends,  in  my 
opinion,  on  something  else, — namely,  the  fact 
that  it  is  free  from  limitations  as  to  place  and 
position.  The  incandescent  lamp  weighs  prac- 
tically nothing;  it  can  be  placed  obliquely  or 
upside  down ;  the  observer  may  have  the  best 
light  without  a  lamp,  as  it  were,  for  he  attaches 
the  lamp  simply  to  his  own  forehead  and  need 
pay  no  further  attention  to  it.  Students  must 
acquire  the  use  of  the  forehead-mirror ;  and, 
even  could  electric  light  be  placed  at  their  dis- 
posal, the  forehead-mirror  would  nevertheless 
be  in  place,  in  my  opinion.  When,  however, 
it  is  not  a  question  of  acquiring,  but  of  prac- 
tising laryngoscopy,  the  forehead-lamp  is  the 
rational  instrument  for  electrical  illumination. 
The  conducting-cords,  which  are  needed  to 
connect  the   forehead-lamp  with   the  battery. 


THE    TECHNIQUE.  11 

are  certainly  not  a  pleasant  addition,  and  re- 
quire a  certain  familiarity.  But  the  connecting 
and  disconnecting  with  the  battery  is  but  little 
trouble,  and  quite  separate  from  the  examina- 
tion itself.  It  differs,  therefore,  decidedly  from 
those  other  inconveniences  which  we  have 
noted  ;  the  long  cords  do  not  in  any  way  inter- 
fere with  our  movement ;  the  forehead-lamp 
leaves  us  entirely  unimi^eded  as  observers  and 
as  operators. 

A  simple  forehead-lamp  which  gives  direct, 
unreflected  light  meets  all  requirements  as  long 
as  we  do  not  wish  to  examine  the  deeper  por- 
tions of  comparatively  narrow  cavities;  but  it 
is  not  well  adapted  to  autoscopy  or  to  anterior 
rhinoscopy,  because  in  these  cases  the  axis  of 
our  vision  cannot  coincide  with  the  axis  of 
the  rays  of  light ;  so  that  either  the  one  or  the 
other  falls  obliquely  upon  the  parts  to  be  illu- 
minated, and  thus  a  clear  view  of  the  deep  por- 
tions is  impossible. 

All  the  demands  of  laryngological  and  rhi- 
nological  technique,  inclusive  of  autoscopy,  are 
met  by  a  forehead-lamp  for  reflected  light  in- 
vented by  me  (Fig.  2),  in  which  the  rays  of  the 


12 


AUT03C0PY. 


electric  light,  after  they  have  been  collected  by 
a  convex  lens,  are  deflected  at  a  right  angle, 
immediately  on  issuing  from  the  lens,  by  a 
small  plain  mirror  (8)  placed  at  an  angle  of 
45  degrees  to  it.  The  mirror  is  perforated  ob- 
liquely through  its  centre  for  the  eye  of  the 
observer.     The  latter  need  pay  no  attention  to 


Fig.  2.— Forehead-Lamp  for  Reflected  Light. 


the  angle  at  which  the  mirror  is  placed,  but  is 
guided  solely  by  a  longitudinal  disc  of  tin  (0) 
placed  vertically  behind  the  mirror  (between  it 
and  the  eye),  and  which  is  also  perforated. 
When  one  can  look  through  both  perforations, 
the  axis  of  vision  coincides,  of  necessity,  with 
the  centre  of  the  bundle  of  light-rays, — an  ideal 


THE    TECHNIQUE.  13 

condition  for  the  purposes  of  vision.  The  lamp 
{L)  is  attached  to  the  head-band  by  means  of 
two  joints  {h  and  a)  in  such  a  way  that  any  de- 
sired motion  within  the  widest  possible  limits 
can  be  carried  out  with  the  least  amount  of 
force,  and  so  that  the  lamp  remains  fixed  in 
any  given  position.  The  lamp  is  moved  from 
one  position  to  another  by  grasping  the  lower 
border  of  the  perforated  tin  disc.  This  latter 
serves  also  to  protect  the  observer  from  the 
heat  of  the  lamp.  A  current  interrupter  {A  E) 
is  attached  to  the  cord. 

For  the  special  purposes  of  autoscopy,  in 
addition  to  the  forehead-lamp,  another  electrical 
appliance  for  illumination  must  be  considered, 
— one  which,  I  think,  will  gain  the  favor  of  lar- 
yngologists.  This  is  the  so-called  electroscope^ 
— an  excellent  instrument  originally  devised  by 
Casper  for  examining  the  urethra,  and  which 
has  been  unessentially  modified  by  me  for  the 
purposes  of  autoscopy.  It  (Fig.  3,  page  16) 
consists  of  an  electrical  hand-lamp,  the  rays  of 
which  are  collected  by  a  lens  and  deflected  90 
degrees  by  a  prism.  This  hand-lamp  is  used  as 
a  handle ;  to  it  the  spatula  {S)  of  the  autoscope 


14  AUTOSCOPY. 

is  fastened  at  a  right  angle  by  means  of  a 
set-screw  (a),  so  that  the  rays  of  the  light  are 
reflected  along  the  spatula, —  an  ideal  optical 
condition  which  can  thus  not  be  disturbed. 
Therefore,  we  need  be  at  no  special  pains  to 
direct  the  light ;  we  have  simply  to  direct  the 
spatula,  and  the  light  must  follow  of  itself. 
Verily,  a  more  convenient  method  of  exami- 
nation cannot  be  thought  of.  The  observer 
looks  immediately  above  the  edge  of  the  prism, 
so  that  he  can  get  a  complete  view  of  the  field 
brilliantly  illuminated  by  the  diverging  rays  of 
light.  Autoscopy  can  hardly  be  demonstrated  to 
others  without  the  use  of  this  electroscope. 


THE   TECHNIQUE. 


II.    THE   AUTOSCOPE. 

The  autoscope  consists  of  three  parts :  a 
spatula,  a  hood,  and  a  handle.  When  the 
spatula  {S,  Fig.  3)  is  pressed  upon  the  pos- 
terior part  of  the  tougue  the  middle  of  the 
tongue  is  depressed  more  than  the  more  fixed, 
lateral  portions,  so  that  a  groove  is  formed 
between  the  palato-glossal  arches ;  it  follows, 
therefore,  that  the  spatula,  as  used  in  auto- 
scopy,  should  have  the  shape  of  a  groove.  The 
narrower  the  groove,  the  less  it  infringes  upon 
the  lateral,  more  fixed  portions  of  the  tongue, 
and  the  more  deeply  therefore  can  it  be  pressed 
into  the  middle  portion  of  the  tougue.  The 
spatula  may  not  be  too  narrow,  however,  be- 
cause the  tongue  would  at  times  rise  up  on  both 
sides  of  it,  and  thus  shut  out  the  light.  As  not 
only  the  tongue,  but  also  the  superior  maxilla, 
must  be  kept  out  of  the  way  of  the  straight  line 
of  vision,  the  spatula  for  autoscopy  must  form 
a  straight  line  from  before  backward ;  only  at 

(15) 


16 


AUTOSCOPY. 


the  end,  where  it  has  akeady  passed  the  con- 
vexity of  the  tongue,  the  ordinary  (prelaryn- 
geal) spatula  is  given  a  downward  curve,  so 
that  it  can  elevate  the  epiglottis  by  exercising 


Fig.  3.— Standard  Spatula  (S)  attached  to  the  Elec- 

TKOSCOPE,   AND    InTRA-DAKYNGEAL    SPATULA    (>S'),    BOTH 

WITH  Hoods  Omitted. 

the  proper  pressure  upon  the  base  of  the  tongue 
(and  thus  also  upon  the  body  of  the  hyoid  bone, 
which  can  always  be  easily  felt  in  the  valleculae) 
and  upon  the  median  glosso-epiglottidean  liga- 
ment.    The  tip  {d,  Fig.  3)  of  the  spatula,  which 


THE    TECHNIQUE.  17 

must  be  thickened  and  well  rounded,  in  order 
to  avoid  injury  to  the  mucous  membranes,  must 
also  be  notched  to  receive  this  latter  ligament. 
The  spatula  for  adults  is  14  centimetres  long ;  at 
the  tii3  it  is  about  2  centimetres  wide,  and  it  is 
about  li  centimetres  wide  where  it  passes  the 
convexity  of  the  tongue.  It  is  made  of  nickel- 
plated  Grerman  silver,  is  exceedingly  easy  to 
clean,  and  can  be  readily  sterilized  in  boiling 
water.  The  tip  of  the  ordinarily  used  standard 
spatula  is  bent  downward  so  that  its  free  border 
is  1  centimetre  below  the  level  of  the  bottom  of 
the  grooved  portion.  Yet,  it  is  desirable  to 
have  two  spatulas  in  addition, —  one  with  a 
larger  curve,  but  especially  one  with  a  smaller 
curve,  to  be  used  in  special  cases,  as  experience 
will  soon  indicate. 

In  cocainized  patients,  especially  for  oper- 
ative puiposes,  the  intra-laryngeal  spatula  can 
be  used.  This  is  introduced  behind  the  epiglot- 
tis, presses  it  against  the  root  of  the  tongue, 
and  thus  hides  it  from  view.  This  intra-laryn- 
geal spatula  (see  S\  Fig.  3)  forms  a  perfectly 
straight  groove,  which  ends  anteriorly  in  a  thin, 
convex  border.     It  is  by  no  means  always  easy 


18  AUToscopy. 

to  introduce  this  spatula,  as  soft  and  very  yield- 
ing epigiottides  readily  escape  its  grasp.  If 
occasion  demand,  one  might  try  to  introduce 
the  prelaryngeal  spatula  with  the  slight  curve 
behind  the  cocainized  epiglottis.  All  the  dif- 
ferent forms  of  spatulas  have  lateral  ribs  (r), 
to  which  the  hoods  are  attached. 

The  hood,  which  is  6  centimetres  long  and 
3  centimetres  wide,  is  also  made  of  nickel- 
plated  metal.  It  serves  to  keep  the  passage 
clear  for  light  and  vision,  which  would  other- 
wise be  obstructed  by  the  close  contact  of  the 
upper  teeth,  or  by  the  upper  lip,  and  possibly 
the  moustache.  By  withdrawing  the  hood  a 
little  it  is  possible  to  lengthen  the  autoscope 
in  examining  very  large  people ;  in  the  same 
way  the  nose  of  the  patient  can  be  protected 
from  contact  with  the  electroscope,  the  upper 
end  of  which  sometimes  becomes  heated.  In 
certain  cases  the  hood  may  be  dispensed  with. 
I  have  had  hoods  made  of  three  different 
heights, — about  3,  6,  and  9  millimetres;  the 
medium -sized  {''''standard  hood'''')  is  the  one 
most  commonly  used ;  the  largest-sized  allows 
the  introduction  of  large  instruments  (forceps, 


THE    TECHNIQUE.  19 

etc.)  for  operative  purposes;  the  small -sized 
one  is  also  occasionally  useful.  It  is  astonish- 
ing through  what  a  narrow  slit  we  can  get  an 
unhindered  view  in  autoscopy ;  a  slit  3  milli- 
metres high  is  amply  sufficient,  though  usually 
we  grant  ourselves  a  greater  allowance. 

Instruments  of  unusual  thickness  cannot  be 


Fig.  4.— PijAix  Hajtdle. 


introduced  even  through  the  largest  hoods  if  we 
employ  the  electroscope,  which  certainly  is  very 
convenient  as  an  illuminating  handle,  but  which 
covers  up,  with  its  prism,  the  entrance  into  the 
grooves,  and  leaves  free  only  the  passage-way 
through  the  hood.  Much  space  can  be  gained 
(though  this  is  very  seldom  necessary)  by  at- 


20 


AUTOSCOPY. 


taching  tlae  spatula  to  a  simple  metallic  handle 
(Fig.  4)  which  is  used  in  connection  with  the 
forehead-lamp  (or  the  forehead-mirror). 

I  have  of  late,*  however,  succeeded  in  dis- 
pensing with  the  hood  by  substituting  a  simple 
plate  for  it  (P,  Fig.  5),  which  is  fastened,  on 


Fig.  5.— Autoscope  with  Plate  (P)  instead  of  Hood. 

its  left  side,  to  the  spatula  by  means  of  a  me- 
tallic bar  (b)  and  a  set-screw  (x) ;  consequently, 
the  lateral  ribs  of  the  autoscopic  spatula  (S) 
are  omitted  and  the  autoscope  is  entirely  open 
on  both  sides.  By  this  means  the  introduction 
of  surgical  instruments  is  greatly  facilitated. 


*  March.  1896. 


THE   TECHNIQUE. 


III.   AUTOSCOPY. 

AuTOSCOPY  is  an  art,  to  begin  witli.  Who- 
ever believes  tliat  simply  by  reading  this  book 
and  by  procuring  an  autoscope  he  will  be  able 
to  use  it  successfully  is  sadly  mistaken.  Auto- 
scopy  is  a  difficult  art,  until  one  has  acquired  a 
certain,  hard-to-define  knack  in  introducing  the 
spatula.  He  who  has  once  mastered  the  use  of 
the  autoscope  will  seldom  meet  special  diffi- 
culties which  he  cannot  easily  overcome. 

We  have  seen,  in  the  chapter  devoted  to  the 
theory,  that  the  axis  of  vision  of  the  patient 
should  in  general  form  a  more  obtuse  angle 
with  the  trunk  than  it  does  in  military  position. 
If  the  patient  who  is  sitting  perfectly  straight 
should  bend  his  head  somewhat  backward,  the 
continuation  of  his  trachea,  though  somewhat 
inclined  toward  the  vertical,  would  project  so 
steeply  upward  that  the  examination  would 
become  inconvenient  for  the  physician.  We 
therefore   tell  the   patient  to   bend  the  whole 

(21) 


22 


AUTOSCOPY. 


upper  part  of  his  body  slightly  forward,  as 
illustrated  in  FigSo  6  and  9  (page  49).  This 
forward  inclination  of  the  body  has  the  further 
advantage  that  the  muscles  of  the  neck  thereby 


Fig.  6.— Position  for  Autoscopy. 

This  photograph  was  taken  from  a  partly  stripped  patient  in  order  to  show 
distinctly  the  position  of  head  and  neck  during  examination. 


become  somewhat  relaxed,  of  which  fact  one 
can  easily  convince  one's  self  by  palpating  the 
sterno-cleido-mastoid  muscles. 

For  the  purpose  of  examination  the  patient 
need  not  undress,  but  might  remove  his  necker- 


THE   TECHNIQUE.  23 

chief  or  a  very  tight  collar.  False  teeth  should/ 
he  removed.  The  physician  stands  in  front  oi 
the  patient,  who  is  seated.  The  autoscope  is 
grasped  with  the  whole  hand — it  is  best  to 
practise  from  the  beginning  with  the  left  hand 
— and  is  introduced  ivell  illuminated^ — under  no 
circumstances  without  the  guidance  of  the  eye.  If 
the  electroscope  is  used, — which  will  probably 
be  the  rule, — the  electric  contact  is  closed  for 
the  purpose  of  illumination  before  the  introduc- 
tion of  the  instrument.  The  spatula  is  intro- 
duced in  such  a  manner  that  its  tip  catches  in 
the  groove  between  the  tongue  and  the  epi- 
glottis. (The  beginner  is  liable  to  rest  the 
spatula  on  the  tongue,  or  he  may  inadvertently 
hook  it  behind  the  epiglottis!)  The  handle  is 
now  raised  until  the  hood  touches  the  upper 
incisors,  care  being  taken  not  to  include  the 
upper  lip  between  the  hood  and  the  teeth 
(avoiding  this,  if  necessary,  with  the  other 
hand),  and  the  base  of  the  tongue  drawn  evenly 
and  steadily  downward  and  forward  as  far  as 
possible  without  exercising  any  force.  During 
all  this  time  the  physician  looks  through  the 
hood,  using  his   better   eye,    and,   if   possible^ 


24  ACToscopy. 

without  glasses.  The  autoscope  may  come  in 
contact  with  the  upper  teeth,  but  must  never 
exert  painful  pressure  against  them. 

If  the  autoscope  is  properly  introduced,  the 
physician  may  take  his  time  and  examine  at  his 
leisure,  while  the  patient  breathes  and  phonates 
quite  at  his  ease.  In  withdrawing  the  instru- 
ment care  must  naturally  be  taken  to  raise  the 
hook-like  tip  by  lowering  the  handle  of  the 
instrument,  thereby  avoiding  the  danger  of 
pulling  the  tongue  forward.  Should  the  patient 
attempt  to  grasp  the  instrument,  it  must  be 
instantly  removed. 

The  proper  manipulation  of  the  autoscope 
requires,  as  already  stated,  a  great  deal  of  prac- 
tice ;  only  those  will  succeed  in  completely  mas- 
tering this  method  who,  from  the  beginning,  lay 
the  blame  for  all  their  failures  in  the  introduc- 
tion of  the  instrument  upon  themselves.  The 
expert  autoscopist  can  be  known  by  two  char- 
acteristics: he  very  seldom  excites  reflex  move- 
ments (retching)  in  the  patient,  and  very  rarely 
pain.  To  attain  this  end  the  physician  must 
work  accurately  and  rapidly,  but  not  brusquely; 
he  must  be  careful,  considerate,  and  must  have 


THE   TECHNIQUE.  25 

a  gentle  and  skillful  touch.  One  should  always 
bear  the  following  maxim  in  mind :  "  The  auto- 
scope  is  an  instrument  in  using  which  the  phy- 
sician can  hurt  every  patient,  but  should  hurt 
noneP  It  is  true  that  most  patients,  even  in 
the  hands  of  the  most  expert  autoscopists,  will 
suffer  some  inconvenience  from  the  first  exami- 
nation. But  this  sensation  is  not  painful;  it 
depends  primarily  upon  the  fact  that  the  base 
of  the  tongue  is  subjected  to  contact  with  a 
hard,  smooth,  and  cold  instrument,— something 
to  which  it  is  not  accustomed,  and  which  is 
opposed  to  its  natural  functions.  If  the  phy- 
sician has  self-assurance  and  tact,  he  can  easily 
reconcile  the  patient  to  manipulations  which 
are  not  altogether  agreeable;  some  physicians 
succeed  better  than  others  in  allaying  the  fears 
of  timid  patients,  and  in  preparing  them  for 
examination.  Individuality  plays  a  large  role 
in  such  matters.  Certainly  the  method  should 
not  be  blamed  for  what  is  due  to  unskillful 
manipulation.  As  a  rule,  the  method  is  pain- 
less and  easily  borne.  It  stands  to  reason  that 
certain  persons  with  exaggerated  sensitiveness 
to  pain  may  be  an  exception  to  the  rule,  and 


/ 


26  AtJTOSCOPY. 

may  suffer  real  pain  from  even  gentle  pressure. 
Comparing  the  two  methods  of  examination, 
laryngoscopy  is,  on  the  whole,  the  more  elegant 
and  gentle  method,  though  there  are  not  a  few 
patients  who  prefer  the  autoscope  to  the  mirror. 
In  the  worst  cases  the  mucous  membranes  may 
be  anaBsthetized  with  cocaine. 

Certain  little  knacks — such  as  changing  the 
position  of  the  patient,  holding  the  autoscope 
obliquely,  or  even  looking  past  it,  which  are 
sometimes  of  advantage — can  be  picked  up  by 
everybody  as  occasion  demands. 

Autoscopy  occasions  the  physician  certain 
annoyances  and  inconveniences,  which  may  be 
summed  up  as  follows : — 

1.  The  expense  of  the  armamentarium  and 
the  trouble  of  acquiring  the  technique. 

2.  The  dependence  on  an  available  and  reli- 
able source  of  electricity  (storage  battery  or 
connection  with  the  street- current).  Auto- 
scopy can,  of  course,  as  stated  before,  be  car- 
ried on  by  means  of  any  sort  of  illumination, 
but  the  electric  light  is  best  adapted  for  freely 
realizing  all  the  advantages  of  this  method. 


THE    TECHNIQUE.  27 

3.  The  physician  is  closer  to  the  breath  of 
the  patient,  and  glasses  become  thus  more  eas- 
ily clouded,  and  he  is  also  more  exposed  to  any 
violent  coughing  spells  of  the  patient,  provided 
he  is  not  careful ;  but  the  disturbance  caused 
by  the  coughing  against  the  laryngeal  mirror  is 
thereby  avoided.  There  is,  however,  a  simple 
remedy  for  the  clouding  of  spectacles  by  the 
breath  of  the  patient.  The  physician  puts  on  a 
forehead- njirror  (intended,  in  this  case,  only  as 
a  protecting  diaphragm)  and  looks  through  its 
central  perforation  ;  by  this  means  the  moisture 
exhaled  by  the  patient  against  the  eye  of  the 
physician  is  almost  entirely  condensed  upon  the 
forehead -mirror,  thus  leaving  the  spectacles 
clear. 

I  am  acquainted  with  no  other  disadvant- 
ages of  the  autoscopic  method  to  the  physician. 
That  there  may  be  certain  disadvantages,  how- 
ever, to  the  patient,  arising  from  autoscopy, 
cannot  be  denied, — if  the  instrument  is  poor 
or  if  the  physician  is  a  bungler ;  but  under 
no  other  conditions.  On  the  other  hand,  the 
act  of  autoscopy  may  occasionally  exert  a  cer- 
tain therapeutic  effect  (be  it  by  pressure  on  the 


28  AUTOSCOPT. 

base  of  the  tongue  or  through  suggestion),  in 
certain  forms  of  parsesthesia,  neuralgia,  or  hys- 
teria ;  so  that  a  few  patients  even  demand  the 
application  of  the  autoscope  again  and  again. 

The  only  contra-indication  to  autoscopy  will 
be  mentioned  hereafter. 


INDIVIDUAL  FITXESS  FOR  THE  AUTO- 
SCOPIC  EXAMINATION. 


As  is  well  known,  the  examination  of  the 
air-passages  by  means  of  the  laryngeal  mirror 
is  possible,  in  the  great  majority  of  cases,  to  a 
rather  uniform  degree.  The  aidoscope,  on  the 
other  hand,  gives  us,  in  some  instances,  a  perfect 
picture  of  the  larynx  and  of  the  trachea;  in  others, 
an  incomplete  picture ;  while  in  still  others  no  view 
at  all  is  obtainable.  The  causes  of  these  individ- 
ual differences  may  be  stated  as  follows:  A 
projection  of  the  anterior  wall  of  the  tracheo- 
laryngeal  tube  forms  a  tangential  plane  (Fig.  7, 
p.  30),  from  which  we  must  remove  the  upper 
jaw  backward  and  the  tongue  (with  the  epiglot- 
tis) forward  in  order  to  obtain  a  complete  auto- 
scopic  view.  The  former  can  be  accomplished 
easily,  as  we  know,  in  all  people  by  a  slight 
tilting  backward  of  the  head  (a  physiological 
rotation  on  the  atlanto-occipital  articulation). 
An  explanation  of  the  difference  must  therefore 
be  sought  in  the  second  factor, — namely,  in  the 

(29) 


30 


AUTOSCOPY. 


possibility  of  depressing  the  tongue.  While  the 
tongue  is  being  depressed  by  the  illuminating 
autoscope,  the  light,  like  a  radius  vector,  at 
first  sweeps  over  the  posterior  wall  of  the  phar- 
ynx from  above  downward,  then  passes  over 


Fig.  7.— Tangential  Plane. 


the  arytenoid  cartilages,  and  lights  up  success- 
ively the  air-passages  from  behind  forward  till 
it  reaches  the  anterior  angle  of  the  glottis. 
During  this  procedure  the  spatula  of  the  auto- 
scope overcomes  the  elastic  resistance  of  the 


FITNESS    FOR    AUTOSCOPIC    EXAMINATION.        31 

tongue,  using  successively  two  fulcrums, — the 
first  a  dorsal  one  (i.e.,  the  root  of  the  tongue,  be- 
tween the  palato-glossal  arches)  and  the  second 
a  basal  one  (i.e.,  the  hyoid  bone  itself  or  imme- 
diately above  it).     A  thorough  and  unhindered 
use  of  the  autoscope  depends,  therefore,  mainly 
upon    the    thickness    and    consistency  of   the 
tongue  and  the  resistance  of  its  lateral  attach- 
ments, and   secondarily  upon  the  mobility  of 
the  hyoid  bone.      Furthermore,   it  is   evident 
that  the  possibility  of  pressing  the  tongue  for- 
ward and   downward  must  be   taken  more  or 
less    advantage   of,   according  to   the  varying 
forms  of  the  head  and  neck.     Let  us  imagine 
the  patient  in  a  position  adapted  to  autoscopy, 
the  tongue  at  rest,  just  before  pressure  is  made 
upon  it  (Fig.  8,  p.  32).     Let  us  now  join  with 
straight  lines   the   point    on  the   back  of   the 
tongue   where   the   pressure  is  made  (Z),  the 
middle  of  the  free  border  of  the  upper  jaw  (0), 
and  the  anterior  commissure  of  the  vocal  cords 
(C).     The  form  and  size  of  the  triangle  Z  0  C 
will  thus  become  the  index  of  the  amount  of  dis- 
location to  which  the  tongue  must  be  subjected 
to  render  autoscopy  jjossible  in  a  given  indi- 


32 


AUTOSCOPY. 


viclual.  For  a  perfect  autoscopic  examination 
(A)  the  radius  vector  mnst  be  carried  forward 
through  the  angle  Z  0  C  (A)',  if  the  condition 
of  the  patient's  tongue  allow  a  movement  only 


through  a  smaller  angle  (r^),  then  A  = 


A 


Fig.   8.— DISPLACE3IENT   OF   TOMGUE   IN    AUTOSCOPY. 


Fitness  for  autoscojDic  examination  varies, 
therefore,  with  each  individual.  To  determine 
this  empirically  requires  a  willing  assistance  on 
the  part  of  the  patient,  which  can  easily  be  ob- 


FITNESS   FOR    AUTOSCOPIC   EXAMINATION.        33 

tained  in  the  vast  majority  of  cases.  This  fit- 
ness would  appear  less  than  it  really  is  should 
the  patient  retch  or  put  his  muscles  on  the 
stretch  through  anxiety.  Should  he  be  able  to 
relax  his  muscles  the  examination  may,  never- 
theless, be  rendered  difficult  at  times  by  a  rigid 
epiglottis,  or  one  with  too  large  a  curve,  or  one 
which  is  so  loosely  attached  to  the  toDgue  that 
it  cannot  be  sufficiently  raised,  and  thus  blocks 
the  view  into  the  laryngo-tracheal  tube,  which 
would  otherwise  be  in  the  direct  line  of  vision. 
Such  cases  are  more  adapted  to  the  intra-laryn- 
geal  autoscopic  spatula,  which  requires  the  use 
of  cocaine,  and  which  should,  therefore,  be  re- 
stricted to  special  indications  only. 

In  examining  a  patient  with  the  autoscope 
we  accomplish  two  things :  (1)  we  determine 
his  special  fitness  for  the  examination  with  the 
autoscope,  and  (2)  we  learn  the  condition  of 
the  parts  open  to  inspection;  both  results  are 
achieved  by  one  and  the  same  act.  According 
to  my  estimate,  in  about  one-fourth  of  all  adults 
the  whole  larynx  and  the  whole  trachea  can  be 
conveniently  examined  autoscopically  («5  =  A ), 
with  this  limitation :  that  the  extreme  apex  of 


34  AUTOSCOPT. 

the  anterior  commissure  cannot  be  seen  nearly 
so  often  (possibly  in  about  one-tenth  of  all 
cases).  About  one-half  of  all  people  can  be 
fairly  well  examined  with  the  autoscope,  so 
that  the  posterior  region  of  the  larynx,  includ- 
ing sometimes  a  more  or  less  extensive  portion 
of  the  trachea,  is  exposed  to  view.  The  remain- 
ing cases  include  those  in  whom  one  cannot  see 
beyond  the  tips  of  the  arytenoid  cartilages,  or 
not  even  so  far,  and  those  who,  owing  to  their 
abnormal  irritability,  cannot  be  examined  at  all 
without  cocaine.  By  pressure  applied  with  the 
thumb  upon  the  middle  of  the  thyroid  cartilage 
the  autoscopic  field  of  vision  toward  the  front 
can  be  considerably  enlarged  in  many,  espe- 
cially in  the  young.  By  means  of  this  manip- 
ulation— which  may  in  operations  be  left  to 
an  assistant — the  anterior  commissure  can  be 
brought  into  view  rather  frequently.  Most 
patients  stand  this  manipulation  well.  Men 
and  women,  so  far  as  I  have  been  able  to  see, 
are  equally  adapted  to  autoscopic  examination. 
Should  any  one  wish  to  make  a  statistical 
investigation  of  these  statements,  let  him  not 
begin  to  count  until  he  has  fully  mastered  the 
entire  technique  of  autoscopic  examination. 


COMPARISON  BETWEEN  AUTOSCOPY 
AND  LARYNGOSCOPY. 


After  having  recognized  and  demonstrated 
the  possibility  of  examining  the  mucous  mem- 
brane of  the  larynx  and  the  trachea  autoscop- 
ically;  after  having  developed  and  tested  a 
thousandfold  a  simple  and  uncomplicated  tech- 
nique; after  having  determined  the  limits  of  its 
usefulness,  and  having  completed  the  requisite 
diagnostic  and  therapeutic  armamentarium; 
after  having,  furthermore,  performed  auto- 
scopic  operations  in  all  parts  of  the  larynx, 
even  up  to  the  anterior  commissure,  I  feel  that 
all  of  these  experiences  are  sufficient  to  justify 
me  in  trying  to  specify  the  position  which 
autoscopy  may  occupy  among  the  methods  of 
laryngological  examination  and  therapy,  and 
in  comparing  it  with  laryngoscopy. 

I.   EXAMINATION  OF  ADULTS. 

It  is  the  investigator  who  is  responsible  for 
the    discovery   and  the    correct   estimation   of 

(35) 


36  AUTOSCOPY. 

facts ;  the  physician  is  responsible  for  the  most 
useful  and  skillful  application  of  these  facts; 
but  no  one  is  responsible  for  the  facts  them- 
selves. It  cannot  be  laid  to  our  door  that  the 
throats  of  many  people  are  so  formed  by  nature 
that  we  cannot  get  a  good  view  of  their  deeper 
portions.  Just  as  little  can  it  be  placed  to  our 
credit  that  the  necks  of  many  other  people  are 
shaped  differently,  and  allow  us  to  see  directly 
down  to  the  sixth  ring  of  a  bronchus  without 
difficulty.  If  we  add  to  our  art  a  new  method 
by  the  aid  of  which  we  can  see  and  touch  with- 
out the  use  of  a  mirror  the  trachea  of  one 
person,  we  ought  certainly  not  to  be  blamed  if 
this  method  is  not  applicable  to  every  other 
person.  It  is  simply  our  duty  to  draw  the 
logical  conclusions  from  such  actual  objective 
experiences  which  we  have  recorded  in  our 
studies.  The  first  of  these  conclusions  is  this : 
We  must  continue  using  the  laryngoscopic  mirror 
now  as  formerly.  This  truth  is  easily  estab- 
lished. 

In  our  consideration  of  the  individual  fit- 
ness for  autoscopic  examination  we  saw  that 
the  mirror  could  be  dispensed  with  in  only  a 


AUTOSCOPY    AND    LARYNGOSCOPY.  37 

certain  number  of  cases,  as  regards  the  exami- 
nation of  the  larynx  and  the  trachea.  If  we 
bear  in  mind  that  the  root  of  the  tongue  (be- 
hind the  papillae  circumvallata^)  can  ordinarily 
be  seen  only  by  means  of  the  mirror  (the  auto- 
scope  covers  this  portion),  it  is  clear  that  the 
laryngoscopic  mirror  can  he  hardly  ever  ivliolly 
dispensed  with  for  a  complete  examination  of  the 
throat.  The  only  contra-indication  to  the  use 
of  the  autoscope  is  a  morbid  condition  of  the 
base  of  the  tongue  or  of  the  valleculae, — a  con- 
dition which  is  rarely  encountered ;  this  can  be 
recognized  only  by  means  of  the  laryngoscopic 
mirror.  It  would  therefore  be  proj)er,  under 
ordinary  circumstances,  to  examine  the  throat 
first  with  the  laryngoscope,  and  not  till  then 
with  the  autoscope;  but  not  much  importance 
need  be  attached  to  this  order  of  procedure. 

My  statement — "  We  must  continue  using 
the  laryngoscopic  mirror  now  as  formerly" — 
might  lead  some  one  to  say :  I  acknowledge 
that  the  discovery  of  the  autoscope  has  en- 
riched our  theoretical  knowledge ;  I  admit  also 
that  in  certain  rare  cases  autoscopy  may  have 
some  special  value ;  on  the  whole,  however,  I 


38  AUTOSCOPY. 

consider  this  innovation  as  useless  for  practical 
purposes,  for  we  continue  using  the  laryngo- 
scope, and  things  are  as  they  were  before.  But 
this  would  be  an  error.  We  continue  using  the 
mirror,  now  as  before,  but  things  are  neverthe- 
less not  what  they  were  before ;  on  the  contrary, 
a  good  many  things  will  be  changed,  although 
this  may  not  take  place  at  once,  nor  every- 
where. Everybody  certainly  has  the  privilege 
of  refusing  to  become  acquainted  with  auto- 
scopy ;  but  whoever  has  once  grown  accus- 
tomed to  its  use  will  soon  no  longer  be  willing 
to  do  without  it.  The  weakness  of  autoscopy 
lies  in  the  limitation  of  its  applicability,  as  just 
explained ;  but  within  the  field  of  its  applicabil- 
ity it  is,  in  almost  every  respect^  superior  to  lar- 
yngoscopy. In  comparing  the  two  methods  we 
must,  once  for  all,  bear  in  mind,  in  speaking  of 
autoscopy,  the  phrase,  "  within  the  limits  of  its 
applicability  in  the  given  individual." 

Under  ordinary  circumstances  the  vocal 
cords  are  seen  at  a  shorter  range  with  the  auto- 
scope  than  with  the  mirror ;  and,  furthermore, 
with  my  method  the  object  itself  is  seen  with 
undiminished  distinctness,  with  all  its  natural 


AUTOSCOPY    AND    LARYNGOSCOPY.  39 

colors  and  shades  of  light;  with  the  method  of 
Oarcia,  Tiirck,  and  Czermak,  however,  only  the 
reflected  image  of  the  object  is  seen,— an  ex- 
cellent  substitute,  but  at  best  only  a  substitute  of 
direct  vision.     It  is  a  matter  of  no  practical  im- 
portance that  the  mirror  permits  of  binocular 
vision,  while  autoscopy  allows  of  only  monoc- 
ular   vision    (just    like    anterior    rhinoscopy). 
Every  anatomical  detail  (such  as  slight  irregu- 
larities of  the  surface,  small  erosions,  etc.)  can 
be  recognized  and  appreciated  far  better  with 
the  autoscope.     It  is  only  in  the  diagnosis  of 
disturbances  of  mobility  that  the  laryngoscope 
is  more  appropriate,  as  the  autoscope  slightly 
immobilizes  the  larynx ;  in  every  other  respect 
autoscopy  is  the  better  method.      The   auto- 
scopic  picture  has  all  the  vivid  freshness  and 
warmth  of  actual  life ;   the  reflected  image  is 
duller  and  colder,  it  is  a  beautiful  art-product, 
and  comes  to  us  at  second-hand.     How  often, 
during  the  past  few  months,  have  I  heard  the 
exclamation:    "The  larynx  looks  entirely   dif- 
ferent /" — which  remark  did  not  refer  to  the  no- 
longer-present  reversal  of  the  image.     Strictly 
interpreted,  this  would  prove  that  hitherto  we 


40  AUTOSCOPY. 

have  not  really  known  liow  the  larynx  actually 
does  look. 

In  the  beginning  of  our  experience  in  auto- 
scopy  it  was  rather  painful  to  feel  that  the  re- 
flected image  was  so  much  less  beautiful  than 
the  autoscopic  picture,  and  that  we,  neverthe- 
less, could  not  dispense  with  it ;  autoscopy  thus 
awakens  a  desire  which  it  cannot  fully  satisfy. 
Autoscopy  is,  therefore,  a  difficult  morsel ;  un- 
til it  is  thoroughly  absorbed  into  'the  life-blood 
of  laryngology  it  will  cause  many  a  digestive 
disturbance. 

For  the  purposes  of  scientific  demonstra- 
tion autoscopy  is  just  the  thing;  a  number  of 
spectators  can  look,  one  after  another,  through 
the  autoscope  and  note  the  conditions.  In 
persons  well  adapted  to  autoscopy  it  is  easy  to 
demonstrate  to  any  layman  the  movements  of 
the  vocal  cord,  the  physiological  pulsation  of 
the  wall  of  the  trachea,  the  systolic  beating 
of  the  bifurcation-spur,  and  quite  as  easily  a 
carcinoma  of  the  larynx. 

The  special  triumph  of  autoscopy  lies  in  the 
possibility  it  affords  of  obtaining,  in  many 
cases,   an  incomparably  complete  view  of  the 


AtJTOSCOPY    AND    LARYNGOSCOPY.  41 

posterior  wall  of  the  larynx  and  tlie  entire  inner 
surface  of  the  trachea,  as  well  as  of  the  entrance 
of  the  bronchi.  There  is  no  special  need  of 
discussing  these  important  points  in  detail. 
Whoever  has  once  obtained  a  good  autoscopic 
view  of  these  parts  requires  no  verbal  explana- 
tion of  the  advantages  it  offers  to  the  eye,  and 
mere  words  can  give  no  adequate  idea  to  him 
who  has  never  seen  it.  I  therefore  refer  the 
reader  to  the  ■  testimony  of  his  own  eyes,  and 
limit  myself  here  to  the  expression  of  my  con- 
viction, corroborated  by  extensive  experience, 
that  autoscopy  has  considerably  advanced  our 
ability  to  diagnosticate,  and  especially  to  treat, 
pathological  conditions  of  the  posterior  laryn- 
geal wall,  the  trachea,  and  the  primary  bronchi. 
Given  a  patient  suffering  from  chronic  tracheo- 
bronchitis, stenosis  of  the  bronchi,  or  something 
similar,  the  cardinal  question  concerning  the 
local  treatment  is  :  Can  he  be  readily  examined 
with  the  autoscope  or  not  1  In  principle  and  in 
theory  we  can  see  and  accomplish  nothing  by 
means  of  the  autoscope  that  we  cannot  do  as 
well  by  means  of  the  laryngoscope ;  but  the 
difference  in  our  practical  results  is,  neverthe- 


42  AUTOSCOPY. 

less,  very  great.  The  posterior  wall  of  the  lar- 
ynx, as  is  well  known,  forms  in  different  people 
a  varying  angle  with  the  longitudinal  axis  of 
the  trachea ;  according  to  this  variation  the 
angle  at  which  it  apjDears  in  the  autoscope  also 
varies.  The  nearer  it  approaches  to  a  right 
angle,  the  better  is  the  view  obtained ;  a  perfect 
surface-view  can  be  obtained,  in  many  cases, 
only  when  the  patient  departs  from  the  normal 
position  and  lowers  his  head  toward  his  breast. 
I  think  that  I  am  able  to  get  a  sufficiently  good 
autoscopic  view  of  the  posterior  wall  of  the 
larynx  in  about  two-thirds  of  all  cases. 

In  practice  it  is  certainly  not  necessary  to 
exhaust  all  of  our  means  in  every  case,  and 
thus  we  need  not  use  the  autoscope  in  every 
patient ;  but  experience  will  soon  teach  any 
unbiased  observer  that  autoscopy  is  necessary 
to  a  complete  and  thorough  examination  of  the 
throat  in  many  cases.  The  more  familiar  we 
become  with  the  autoscope,  the  more  we  shall 
learn  to  regret  that  the  possibility  of  being  ex- 
amined thoroughly  and  satisfactorily  with  this 
instrument  is  not  a  universal  characteristic  of 
the  human  race. 


AUTOSCOPY    AND    LARYNGOSCOPY.  43 

There  is  no  theoretical  objection  to  the 
employment  of  magnifying  instruments  in  auto- 
scopy,  to  the  use  of  OerteVs  stroboscope  (stro- 
bantoscopy  of  the  larynx). 

I  can  also  recommend  to  snch  of  my  col- 
leagues as  have  experience  in  photography 
to  try  to  photograph  the  larynx  through  the 
autoscope. 

In  this  connection  I  may  mention  a  proced- 
ure not  strictly  autoscopic,  but  made  possible 
by  means  of  autoscopy,  which  consists  in  the 
inspection   of  the  under  surface   of  the  vocal 
cords  by  means  of  a  small,  round  mirror  8  mil- 
limetres in  diameter ;  this  mirror  is  introduced, 
through  the  autoscope,  beneath  the  glottis  of 
the  cocainized  patient.    The  subglottic  mirror 
is  fastened  to  a  very  thin,  nickel-plated  rod  of 
copper,  which  may  be  bent  to  suit  the  require- 
ments of  the  case.    Hitherto  the  view  of  the 
under  surface  of  the  vocal  cords  (first  obtained, 
as  far    as  I  know,  by  Eauchfuss)    could   be 
gained  only  as  a  twice-reflected  image,  for  the 
lower  image  had  to  be  reflected  once  more  by  a 
mirror  higher  up ;  thus  the  picture  was,  so  to 
speak,  "  third-hand  " ! 


COMPARISON    BETWEEN  AUTOSCOPY 
AND  LAEYNGOSCOPY. 


II.   EXAMINATION   OF   CHILDKEN. 

Childeen  are  examined  with  the  antoscope 
in  the  same  manner  as  adults,  but  the  spatulas 
used  are  shorter  (12  centimetres)  and  narrower. 
Though  the  shape  of  the  epiglottis  in  children 
is  not  well  adapted  to  laryngoscopy,  it  does 
not  offer  so  great  an  obstacle  to  autoscopy,  in 
which  the  epiglottis  is  raised.  The  success  of 
autoscopy  in  children  depends  more  or  less 
upon  circumstances.  Obstreperous  children, 
who  will  not  allow  any  manipulation,  can  be 
made  to  submit  to  the  examination  by  force. 
It  is  obvious  that  this  is  a  dangerous  procedure 
in  inexperienced  hands.  I  do  not  at  all  recom- 
mend it,  but  simply  wish  to  state  that  it  can 
easily  be  done.  In  struggling  children  the 
entrance  to  the  larynx  appears  contracted  ;  the 
epiglottis,  the  arytenoid  cartilages,  and  the  ary- 
epiglottic  folds  are  readily  seen,  and  this  is 
often  sufficient  for  a  diagnosis  in  children. 
(44) 


AUTOSCOPr    AND    LARYNGOSCOPr.  45 

I  have  frequently  made  autoscopic  examina- 
tions of  children  under  the  influence  of  an  an- 
aesthetic ;  this  was  accomplished  with  the  great- 
est ease   and  to  the  fullest  extent ;   in  fact,  I 

have  come  to  the  opinion  that  the  equation  — 

is  comparatively  favorable  in  children.  The 
head  of  the  chloroformed  child  is  drawn  over 
the  edge  of  the  table  and  is  held  by  an  assist- 
ant. The  autoscope  is  now  introduced  with 
the  left  hand,  the  spatula  directed  downward, 
and  the  base  of  the  tongue  is  then  pressed  for- 
ward in  the  usual  manner  with  the  spatula ;  the 
head  of  the  child  is  now  gradually  raised  or 
lowered  until  the  correct  position  is  obtained. 
In  this  attitude  a  bougie  can  be  pushed  readily 
into  the  larynx,  or  intubation  may  be  per- 
formed under  favorable  circumstances.  Should 
one  desire  to  use  the  intra-laryngeal  spatula, 
cocaine  could  probably  not  be  dispensed  with, 
even  though  chloroform  were  employed.  I 
would  be  loath,  however,  to  use  cocaine  during 
anaesthesia,  not  so  much  from  fear  of  intoxica- 
tion, but  on  account  of  the  danger  of  aspiration 
when  the  entrance  of  the  larynx  is  completely 
anaesthetized. 


46  AUTOSCOPY. 

In  all  probability  autoscopy  will  assume  an 
important  role  in  the  examination  of  children, 
— on  an  equal  footing  with  laryngoscopy ;  but  in 
preference  to  laryngoscopy  in  very  young  chil- 
dren. Even  infants  can  be  examined  with  the 
autoscope ;  they  are  most  easily  examined  in 
the  dorsal  position,  as  just  described,  naturally, 
without  the  use  of  an  anaesthetic. 


COMPARISON  BETWEEN  AUTOSCOPY 
AND  LARYNGOSCOPY. 


III.   OPERATIONS. 

We  now  come  to  the  consideration  of  anto- 
scopy  in  its  relations  to  the  technique  of  local 
treatment.  It  is  immaterial  whether  we  carry 
out  such  common  procedures  as  iDJections,  in- 
sufflations, applications  with  the  brush,  etc., 
according  to  the  old  or  the  new  plan,  in  patients 
well  adapted  to  autoscopy.  I  will  therefore 
confine  myself  to  the  consideration  of  operative 
procedures.  Autoscopy  is  veritaUy  a  surgical 
method;  it  exposes  the  larynx  in  the  depth  of 
the  throat  with  a  speculum,  in  about  the  same 
way  as  the  portio  vaginalis  uteri  is  exposed  by 
the  distension  of  the  vagina.  When  I  have  once 
brought  a  tumor  to  view  through  the  autoscope, 
I  simply  have  to  attack  it  straightway  with  for- 
ceps, knife,  or  snare,  in  whatever  manner  is 
most  suitable.  For  this  purpose  I  control  the 
autoscope  with  my  left  hand  and  introduce  the 
instrument  with  my  right   hand  between   the 

(47) 


48  AUTOSCOPY. 

hood  and  the  spatula,  along  its  right  side.  The 
handle  of  the  surgical  instrument  can  be  held, 
according  to  the  requirements  of  the  case, 
parallel  with  the  handle  of  the  autoscope  or  at 
any  desired  angle  to  it.  There  is  no  room  in 
the  autoscope  for  extensive  lateral  movements 
of  the  surgical  instrument ;  but  this  is  no  loss, 
for  we  can  seize  nothing  that  we  do  not  dis- 
tinctly see,  and  we  can  see  only  that  distinctly 
which  is  brought  well  into  view  through  the 
autoscope.  With  our  left  hand  we  must  closely 
control  the  position  of  the  autoscope ;  our  right 
hand  remains  free  for  the  more  delicate  manip- 
ulations.    (Fig.  9.) 

The  instruments  for  autoscopic  operations 
are  shaped  like  nasal  instruments;  they 
measure  20  centimetres  from  the  knee  to  the 
tip,  and  are  correspondingly  longer  for  the 
windpipe.  We  are  not  under  the  necessity  of 
devising  new  instruments;  we  simply  trans- 
form our  ordinary  into  an  autoscopic  armamen- 
tarium (Fig.  10,  page  50)  by  having  our  laryn- 
goscopic  models  lengthened  and  bent,  and  the 
rhinological  ones  simply  lengthened. 

Endolaryngeal  operations  are  comparatively 


AUTOSCOPY    AND    LARYNGOSCOPY. 


49 


easy  with  the  autoscope  and  comparatively 
difficult  with  the  laryngoscope.  This  fact 
might  cause  dissensions  among  laryngologists. 


Fig.  9.— Atjtoscopic  Opekation. 


To  some  it  will  appear  self-evident  that  we 
should  not  make  a  difficult  operation  out  of  an 
easy  one,  that  we  should  not  construct  obstacles 
just  for  the  pleasure  of  overcoming  them,  and 


50 


AUTOSCOPY. 


that  we  should  not  seek  to  exercise  the  excep- 
tional skill  of  a  specialist  when  ordinary  surg- 


FiG.  10  —Types  of  Instruments  for  Atttoscoptc  Operations. 

ery  is  wholly  adequate.  On  the  other  hand, 
there  are  teachers  who  will  warn  their  pupils 
against  spoiling  themselves  by  practising  auto- 


AUTOSCOPY    AND    LARYNGOSCOPY.  51 

scopy,  instead  of  using  every  opportunity  to 
operate    under   the    guidance    of    the    mirror; 
arguing  that   operators   will  have   to   use   the 
laryngoscope  in  the  future  just  as  in  the  past, 
as  there  always  will  be  many  patients  requiring 
operations  who  are  poor  subjects  for  autoscopy. 
We  can  imagine  a  laryngological  parliament  the 
radical  wing  of  which,  as  a  matter  of  principle, 
would  operate  with  the  aid  of  the  laryngoscope 
only  in  those  cases  not  adapted  to  autoscopy, 
while   the   conservatives  would  tolerate  auto- 
scopic    manipulations    only  under  exceptional 
circumstances;     the    centre,    however,    would 
decide  each  case  on  its  merits.     In  my  opinion, 
the  question  does  not  justify  a  position  either 
on  the  extreme  right  or  left.     To  make  a  battle- 
cry  of  the  autoscope,  on  the  one  hand,  or  the 
laryngoscope,    on   the    other,   would  be  folly. 
Where   two  ways  are    open,   some  for   many 
reasons  will  prefer  one,  while  others  prefer  the 
other;    we  can  ask  no  more   of  any  operator 
than  that  he    should    perform   any  necessary 
operation  with  nicety  and  care.    How  he  does 
it  is  a  matter  of  taste.     If,  in  spite  of  this,  I 
nevertheless  believe  that  finally,  in  the  course 


52  AUTOSCOPY. 

of  years,  autoscopy  will  be  generally  accepted 
— of  course,  not  as  a  matter  of  dogma — as  the 
standard  method  for  endolaryngeal  and  endo- 
tracheal surgery  in  those  cases  in  which  it 
can  be  easily  used,  I  base  this  conclusion  on 
human  nature,  which  does  not  obstinately  hold 
on  to  a  complicated  procedure  when  a  simple 
one  is  at  its  disposal.  Whatever  resistance 
arises  from  custom  (and  this  I  by  no  means 
undervalue)  will  of  itself  grow  weaker  with 
time,  and  the  argument  that  we  have  got  along 
so  far  without  autoscopy  will  lose  its  force  after 
awhile.  Autoscopic  operations  on  the  posterior 
wall  of  the  larynx  will  become  common  prop- 
erty of  laryngologists  more  quickly  (or,  rather, 
less  slowly)  than  the  other  autoscopic  pro- 
cedures. 

Autoscopy  comes  in  competition  with 
general  surgery  in  only  one  class  of  cases, 
—namely,  in  foreign  bodies  in  the  air-passages ; 
here  it  will  render  tracheotomy  unnecessary  in 
some  cases. 

Concerning  endotracheal  local  therapeutics-^ 
which  can  now  reach  a  development  whiqh  was 
denied  to  it  in  the  pre-autoscopic  era,  I  should 


AUTOSCOPY   AND   LARYNGOSCOPY.  53 

like  to  raise  a  finger  of  warning,  as  a  result  not 
of  unfortunate  experiences  of  my  own,  but  of 
observation  and  reflection.  The  lower  half  of 
the  trachea  is  a  region  of  great  danger!  The 
rhythmical  bulging  of  its  wall,  especially  the 
tracheal  aortic  pulse,  which  can  be  easily  ssen 
toward  the  left  and  somewhat  anteriorly,  and 
readily  counted,  is  a  constant  and  impressive 
phenomenon  in  people  well  adapted  to  auto- 
scopy,  which  should  lead  to  the  greatest  caution 
in  the  introduction  of  rigid  instruments.  The 
aorta  lies  almost  in  as  close  contact  with  the 
'wall  of  the  windpipe  as  the  radial  artery  does 
with  the  surface  at  the  wrist  (reference  is  made 
only  to  the  aorta  distended  with  blood,  as  it  is 
during  life,  and  not  to  the  conditions  existing 
after  death).  During  the  examination  of  a 
number  of  healthy  people  the  aortic  arch  has 
often  seemed  to  protrude  like  a  hump,  as  it 
were,  into  the  trachea ;  so  that  the  beginner  in 
autoscopy  would  be  tempted  to  diagnosticate 
an  aneurism  where  none  exists.  I  have  seen 
the  most  enormous  pulsations  in  patients  suf- 
fering from  aortic  insufficiency,  in  whom,  how- 
ever,  there  was  no   evidence  of  actual  aneu- 


54  AUTOSCOPY. 

rismal  changes ;  in  such  cases  I  have  seen  very 
marked  undulations  over  an  area  about  6  to  8 
centimetres  long  and  3  centimetres  wide. 


CONCLUSION. 


Whoever  believes  in  uninterrupted  progress, 
in  small  things  as  well  as  in  large,  may  nurture 
the  hope  that  in  the  future  autoscopy  will  be 
developed  to  such  an  extent  that  it  can  ulti- 
mately be  applied  to  every  individual.  This 
hope,  however,  I  cannot  share.  The  problems 
of  aiitoscopy  are  confined  within  exceedingly 
narrow  limits;  their  determining  factors  are 
well  known,  and  I  have  expounded  them  suf- 
ficiently in  this  monograph.  The  limitations 
of  autoscopy  are  of  an  anatomical  nature,  and 
the  structure  of  our  bodies  will  scarcely  accom- 
modate itself  to  our  wishes.  If  we  cannot  get 
the  tongue  out  of  the  way  toward  the  front,  we 
shall  have  to  look  over  it, — that  is,  around  a 
curve, — and  for  this  purpose  a  mirror  or  a 
prism  is  absolutely  indispensable ;  thus,  we 
come  back  to  where  we  started.  I  know  of  but 
one  way  in  which  any  special  advance  over  the 
results  already  achieved  is  possible.  By  draw- 
ing the  angle  of  the  patient's  mouth  sideways 

(55) 


56  AUTOSCOPY. 

toward  his  ear  with  a  retractor,  applying  the 
spatula  over  the  lower  molars  to  the  base  of  the 
tongue,  and  pressing  the  corresponding  half  of 
the  tongue  forward,  we  sometimes  obtain  a 
very  good  side-view  of  the  larynx,  even  in 
persons  who  are  poor  subjects  for  ordinary 
autoscopy.  This  lateral  autoscopy  is  worth 
further  attention.  In  this  connection  I  can 
also  recommend,  as  a  useful  aid  in  the  exami- 
nation of  the  lateral  portions  of  the  pharynx,  the 
tonsillar  region,  etc.,  the  drawing  back  of  the 
angle  of  the  mouth  on  the  opposite  side ;  this  is 
done  by  the  physician  or  by  the  patient  himself, 
either  with  a  finger  or  with  a  retractor.  In 
other  respects  I  now  consider  the  problems  of 
autoscopy  definitely  settled^ — until,  at  least,  an 
entirely  new  creative  thought  arises  to  open  up  a 
new  path. 


EESUME. 


1.  The  human  larynx  and  trachea  can  be 
examined  autoscopically ;  that  is,  they  are 
accessible  to  direct  inspection;  the  means  to 
this  end  is  pressure  on  the  tongue. 

2.  The  individual  adaptability  to  autoscopy 
varies  within  wide  limits ;  the  reasons  are  of  an 
anatomical  nature. 

3.  Laryngoscopy  is  no  longer  the  only 
method  of  examining  the  air-passages  as 
hitherto  ;  but  it  will  continue  to  be  the 
standard  method  and  the  one  to  be  used  above 
all  others  for  the  purpose  of  diagnosis. 

4.  Autoscopy  is  an  important  addition  to 
laryngoscopy,  especially  for  examining  the  pos- 
terior wall  of  the  larynx  and  the  trachea. 

5.  In  the  examination  of  children  autoscopy 
is  indispensable  in  some  cases ;  especially  with 
the  aid  of  chloroform  anaesthesia,  it  can  be  car- 
ried out  without  any  great  difficulty. 

6.  In  endolaryngeal  and  endotrachecd  surgery 

(57) 


58  AUTOSCOPY. 

autoscopy  will  take  the  front  rank  as  the  standard 
method;  of  course,  within  its  anatomical  limits. 

7.  The  technique  of  laryngoscopic  oper- 
ations remains  the  same,  and  must  continue  to 
be  used  in  those  patients  who  are  ill-adapted  to 
autoscopy. 


APPENDIX. 


THE  FIRST  AUTOSCOPIC  OPERATION  ON  A 
TUMOR  OF  THE  VOCAL  CORD. 

Mrs.  Wilhelmine  Konig,  set.  39,  small, 
slender,  ill-nourished;  had  been  coughing  for 
three  years;  had  haemoptysis  two  years  ago; 
had  been  hoarse  since  August,  1895.     Dullness 


Fig.  11.— Tumor  of  Vocal  Cord. 


over  the  right  apex  down  to  the  second  rib; 
respiratory  murmur  weak;  no  rales.  Sputum 
not  obtainable.  Upper  teeth  carious  and  partly 
lost.  Marked  hoarseness.  Examination  with 
the  laryngoscope  revealed  a  condition  repro- 
duced in  the  illustration.  (Fig.  11.)  The  right 
arytenoid    cartilage    was    tipped    considerably 

(59) 


60  AUTOSCOPY. 

forward;  the  right  vocal  cord  was  immovable 
in  the  cadaveric  position  and  its  free  edge  was 
concave.  The  left  vocal  cord  possessed  normal 
mobility,  and  during  phonation  extended  only 
to  the  median  line.  In  its  anterior  portion, 
close  to  the  anterior  commissure,  was  a  pink, 
round  tumor,  the  size  of  a  millet-seed,  and 
dotted  on  its  apex  with  a  small,  red  point.  The 
tumor  was  attached  to  the  edge  of  the  vocal 
cord,  and  was  movable.  The  patient  could  be 
examined  with  the  autoscope  so  well  that  the 
tumor,  notwithstanding  its  unfavorable  local- 
ity, could  be  readily  seen  as  the  autoscope  was 
introduced. 

Operation. — On  October  26,  1895,  the  larynx 
was  cocainized  by  instillation  of  a  20-per-cent. 
solution  of  cocaine  (without  the  aid  of  a 
mirror).  The  autoscopic  intra-laryngeal  spatula 
fastened  to  the  electroscope  was  passed  behind 
the  epiglottis  and  controlled  with  the  left  hand. 
The  tumor  was  seized  and  removed  with  the 
greatest  ease  with  a  small,  cutting,  double 
curette  (in  the  straight  tube  and  handle  of 
Krause).  The  patient  was  not  aware  of  the 
operation,   which    lasted    but    a  few  seconds. 


APPENDIX.  61 

Result  of  the  operation:  The  left  vocal  cord 
is  now  normal.  The  hoarseness  was  little  im- 
proved at  first,  as  was  to  be  expected  in  a  case 
of  paralysis  of  the  recurrens  on  the  right  side. 
Four  weeks  after  the  operation  the  left  vocal 
cord  began  to  approach  the  paralyzed  cord  dur- 
ing phonation.  Since  the  beginning  of  Decem- 
ber, 1895,  return  of  the  voice,  notwithstanding 
the  continuance  of  the  paralysis  of  the  recur- 
rens. During  phonation  the  left  vocal  cord 
now  comes  in  contact  with  the  right  cord. 
By  the  middle  of  January,  1896,  the  paralysis 
had  disappeared  and  the  patient  was  entirely 
restored. 


ADDITIONAL  NOTES  OF  THE  TRANS- 

LATOE. 


I.  A  FOKEIGN  BODY  EEMOVED  FROM  THE  LARYNX 
BY  THE  TRANSLATOR. 

Mr.  C.  F.  B.,  ast.  24,  consulted  me  on  March 
25,  1896.  He  stated  that  while  eating  some 
stewed  chicken,  two  days  before,  he  suddenly 
felt  something  "  go  the  wrong  way."  He  had 
subsequently  a  severe  coughing  spell  and  some 
choking  sensations,  which,  however,  soon  sub- 
sided. In  order  to  remove  the  foreign  body 
an  emetic  had  been  taken,  but  without  avail. 
Since  that  time  he  had  had  occasional  coughing 
spells,  but  felt  otherwise  well.  He  was  sure,  he 
stated,  that  a  foreign  body,  probably  a  bone, 
was  somewhere  lodged  in  his  throat,  although 
there  was  no  difficulty  in  swallowing,  nor  any 
pain  worth  mentioning. 

The  patient  was  a  strong,  young  man,  of 
more  than  average  size.  No  signs  of  distress 
were  noticeable.  There  was  no  dyspnoea,  nor 
(62) 


ADDITIONAL    NOTES.  63 

any  tenderness  of  the  neck  on  pressure.  The 
voice  was  slightly  husky.  Laryngoscopic  ex- 
amination revealed,  in  the  extremely  large 
larynx,  a  longitudinal  piece  of  bone,  the  one 
end  of  which  seemed  to  be  imbedded  in  the 
right  ventricle,  while  the  other  end  leaned 
against  the  left  ary-epiglottic  ligament.  The 
upper  end  seemed  not  to  be  impacted.  It  was 
evident  that  this  patient's  larynx  was  not  very 
irritable.  The  autoscope  was  introduced  with 
the  medium-sized  hood  attached.  No  cocaine 
was  deemed  necessary.  It  was  possible  to 
grasp  the  foreign  body  readily  with  a  slender, 
serrated  forceps  in  Krause's  straight  tube  and 
universal  handle,  and  to  lift  it  out  of  the  larynx 
and  remove  it  together  with  the  autoscope. 
The  removed  piece  of  bone  was  nearly  four 
centimetres  long.  The  whole  operation  took 
but  a  few  seconds. 

II.  LATEST  IMPKOVEMENTS  IN  AUTOSCOPY. 

While  the  preceding  pages  were  going 
through  the  press  Dr.  Kirstein  published  some 
modifications  of  his  method,*  which  I  append, 

*  Therapeutische  Monatshefte,  July,  1896. 


64  AUTOSCOPY. 

in  abstract,  in  order  to  bring  this  essay  up  to 
date : — 

The  main  impediments  to  a  thorough  ex- 
amination of  the  deeper  portions  of  the  throat 
are,  as  has  been  previously  pointed  out,  the 
tongue  and  the  epiglottis.  If  we  were  able  to 
remove  these  impediments  there  would  be  noth- 
ing to  prevent  an  inspection  (and  possibly  a 
palpation),  through  the  mouth,  of  the  laryngo- 
tracheal tract.  Kirstein  has  now  fully  demon- 
strated that  this  principal  impediment  —  the 
tongue  —  can  be  removed  from  the  pathway 
of  straight  rays  of  light,  thrown  directly  into 
the  laryngo-tracheal  tube,  a  great  deal  farther 
than  we  had  ever  suspected.  The  amount  of 
displacement,  it  is  true,  varies  greatly  in  differ- 
ent subjects. 

It  has  lately  been  found  that  for  ordinary 
examination  a  complicated  appliance  is  not 
necessary.  A  tongue-depressor,  constructed 
on  the  lines  of  the  one  shown  on  next  page,  will, 
in  most  cases,  be  sufficient.  The  patient  should 
be  seated,  should  tilt  the  head  slightly  back- 
ward (as  described  on  page  21 ;  see  also  Figs. 
6  and  9),  and  the  physician  stands  before  the 


ADDITIONAL    NOTES.  65 

patient.  The  spatula  is  then  placed  far  Lack 
upon  the  tongue, —  as  far  as  possible, —  and 
a  firm  pressure  in  a  downward  and  forward 
direction  is  exercised  upon  the  root  of  the 
tongue,  whereby  a  deep  and  slanting  groove 
is  formed  along  the  back  of  the  tongue,  thus 
allowing  the  rays  of  light  to  fall  in  line  with 


Fig.  12.— Tongue-Depressor  for  Phaeyngoscopy  and 
Direct  Laryngo-Tracheoscopy. 

Side-view  and  surface-view  of  the  anterior  portion.    In  some  cases  an  instrument  with  a 
larger  curve  of  the  anterior  portion  is  more  practicable. 

an  imaginary  laryngo-tracheal  axis.  With 
proper  illumination  we  are  now  enabled  to 
get  a  good  view  of  the  air-passages.  The  ex- 
tent of  this  view  depends,  of  course,  upon  the 
individuality  of  the  patient,  as  stated  in  a  pre- 
vious chapter  (page  29),  and  upon  the  skill  of 
the  examiner.    Many  apparently  unsurmount- 


66  AUTOSCOPY. 

able  difficulties  may  be  overcome  by  patience 
and  practice. 

There  are,  however,  some  tongues  which  are 
so  "  stubborn,"  as  it  were,  that  it  is  well-nigh 
impossible  to  completely  overcome  their  resist- 
ance to  this  manipulation.  As  the  source  of 
illumination  we  may  use  an  ordinary  forehead- 
reflector,  or,  still  better,  Kirstein's  electric  fore- 
head-lamp (Fig.  2).  If  during  this  examination 
the  upper  lip  or  a  moustache  should  obstruct 
the  vision,  the  other  hand  will  readily  remove 
this  obstacle. 

In  this  way  we  shall  be  enabled  to  see,  in 
the  vast  majority  of  cases,  the  posterior  wall 
of  the  larynx;  in  a  good  many  cases  the  pos- 
terior two-thirds  of  the  vocal  cords  can  be  seen, 
and,  although  rarely,  the  whole  interior  of  the 
larynx,  including  the  anterior  commissure  of 
the  vocal  cords,  is  exposed  to  a  thorough  in- 
spection. 

The  extent  to  which  the  trachea  may  be 
seen  is  larger  or  smaller  in  proportion  to  the 
view  obtained  of  the  interior  of  the  larynx. 
There  are,  however, — and  we  must  not  forget 
it, — certain  limitations  to  this  method  which 


ADDITIONAL    NOTES.  67 

we  cannot  overcome,  also  not  by  brusquely 
increasing  the  i)ressure  upon  the  tongue;  al- 
though we  may,  in  cocainized  patients,  during 
operations,  be  a  little  more  energetic. 

For  simple  autoscoj^ic  examination  the  spat- 
ula, or  tongue-depressor,  alone  will  be  sufficient. 
As  this  tongue-depressor  is  available  also  for 
ordinary  pharyngoscopy,  there  is,  in  reality, 
nothing  needed  for  autoscopy  which  we  do  not 
already  possess  in  our  armamentarium.  The 
more  complicated  instrument  described  on  page 
15  will  henceforth  be  used  more  especially  for 
operations,  clinical  demonstrations,  and  in  the 
examination  of  children. 

In  this  connection  it  may  be  repeated 
that  the  laryngological  examination  of  chil- 
dren will  immeasurably  be  aided  by  the  auto- 
scopie  method.  The  larynx  and  trachea  can 
be  examined,  in  children  who  are  anaesthetized, 
with  such  thoroughness  as  was  never  before 
possible. 

It  is  frequently  feasible,  especially  in  young 
children,  to  dispense  altogether  with  the  an- 
aesthesia, and  yet  to  get  a  good  view  of  the 
laryngo-tracheal  tube. 


68  AUTOSCOPY. 

In  conclusion,  it  must  be  repeated  that  auto- 
scopy  is  an  art  that  requires  study  and  practice : 
the  art  of  pressing  into  the  tongue  with  a  mini- 
mal amount  of  irritation  a  longitudinal  groove, 
reaching  backward  and  downward  as  far  as  pos- 
sible, and  approximating  in  direction  to  the  axis 
of  the  laryngo-tracheal  tract. 


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Autoscopy  of  ike  Larynx  and  the  Trachea.  (Direct  ex- 
amination without  mirror.)  By  Alfeed  Kiestein, 
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